REFERENCES:
Give name, address and telephone number of references not related to you. 
Last or current employer to be included.

Please state any additional information you feel may be helpful to us in considering your application.
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Do you have any knowledge or have you withheld any information that would preclude you from performing certain jobs?  qYes q No    If yes, please describe: ________________________________

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APPLICANT'S STATEMENT

I certify that answers given herein are correct, true, and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.  I authorize you to contact the references listed above.  In compliance with the Fair Credit Reporting Act 9Public Law 91-508), you are notified that in connection with and in order to better evaluate this application for employment a report may be obtained which will provide applicable information concerning character, general reputation, and personal characteristics.  I understand that this application is not and is not intended to be a contract of employment.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.   I understand, also, that I am required to abide by all rules and regulations of the Agency.

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          Signature of Applicant                                                                     Date